Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural MozambiqueReportar como inadecuado

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Implementation Science

, 12:50

First Online: 13 April 2017Received: 20 August 2016Accepted: 06 April 2017DOI: 10.1186-s13012-017-0582-z

Cite this article as: Audet, C.M., Salato, J., Vermund, S.H. et al. Implementation Sci 2017 12: 50. doi:10.1186-s13012-017-0582-z


BackgroundSystematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy ART are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV PLHIV for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system.

MethodsAdaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing ADAPT-ITT model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients.

ResultsTraditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 94% accepted.

ConclusionsSystematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers—an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.

KeywordsIntervention adaptation HIV-AIDS Mozambique Community-based support HIV adherence AbbreviationsADAPT-ITTAssessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing

ARTAntiretroviral therapy

CDCCenters for Disease Control and Prevention

PEPFARPresident’s emergency plan for AIDS relief

PLHIVPersons living with HIV

sIMB-CIMSituated-information motivation behavioral skills model of health care initiation and maintenance

SSASub-Saharan Africa

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Autor: Carolyn M. Audet - José Salato - Sten H. Vermund - K. Rivet Amico


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